Nuances, Narratives, and the “Chemical Imbalance” DebatePublished on Psychiatric Times(http://www.psychiatrictimes.com)

Nuances, Narratives, and the “Chemical Imbalance” DebateApril 11, 2014 | Couch in Crisis [1], Cultural Psychiatry [2], Psychopharmacology [3]By Ronald W. Pies, MD [4]

It is time for psychiatry’s critics to drop the conspiratorial narrative of the “chemical imbalance” andacknowledge psychiatry’s efforts at integrating biological and psychosocial insights.

Religions, cultures, and political groups all have theirnarratives—usually favorable or flattering accounts of their origins and beliefs. But narratives are notthe same as truths, and usually lack the nuances of truth, which is rarely black or white. To see howthis applies to psychiatry, try answering the question: Which one of the following statements bestcharacterizes the American Psychiatric Association’s 2005 position on the causes of mental illness?

1. All mental illness is caused by specific and identifiable chemical imbalances in the brain.2. The most serious mental illnesses, such as schizophrenia and major depression, are caused byspecific chemical imbalances.3. Chemical imbalances of some sort cause some mental illnesses.4. The exact causes of mental disorders are unknown.Now, if you were to give credence to a recent online polemic posing as investigative journalism, youwould probably choose the first or second statement.1 In the narrative of the antipsychiatrymovement, a monolithic entity called “Psychiatry” has deliberately misled the public as to thecauses of mental illness, by failing to debunk the chemical imbalance hypothesis. Indeed, thisnarrative insists that by promoting this simplistic notion, psychiatry betrayed the public trust andmade it seem as if psychiatrists had “magic bullets” for psychiatric disorders. (Lurking in theback-story, of course, is Big Pharma, said to be in cahoots with psychiatry so as to sell more drugs.)However, if you had actually investigated the APA’s 2005 statement, you would have chosen answer4. Here is the complete passage from the APA’s “Healthy Minds” Web site, intended for the generalpublic:The exact causes of mental disorders are unknown, but an explosive growth of research hasbrought us closer to the answers. We can say that certain inherited dispositions interact withtriggering environmental factors. Poverty and stress are well-known to be bad for your health—this istrue for mental health and physical health. In fact, the distinction between “mental” illness and“physical” illness can be misleading. Like physical illnesses, mental disorders can have a biologicalnature. Many physical illnesses can also have a strong emotional component [italics added].2

In fact, in the same year as the APA statement, Drs Thomas Insel and Remi Quirion3 wrote a seminalpaper proposing that “mental disorders need to be addressed as disorders of distributed brainsystems with symptoms forged by developmental and social experiences.” They went on to considerhow “environmental factors during critical intervals of development exert long-term effects on geneexpression” and suggest that “studying unconscious processes, motivation, or defenses, while at onetime the sole province of psychoanalytic therapies, are now also in the domain of cognitiveneuroscience.”Does this sound like a simplistic chemical imbalance hypothesis? I don’t think so. But then, why doantipsychiatry groups and bloggers fail to note the nuances of what psychiatrists have been sayingfor at least the past decade? My guess is that doing so would undermine the derogatory narrative

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Nuances, Narratives, and the “Chemical Imbalance” DebatePublished on Psychiatric Times(http://www.psychiatrictimes.com)

they wish to promote. And, of course, nuanced statements do not gin up public opinion or sell books.OK—but weren’t there many psychiatrists in the 1980s and 1990s who advocated a purelybiochemical theory of mental illness, often using the metaphor of the chemical imbalance to explainmental disorders to their patients? It’s difficult to answer this question, except in an anecdotal way,but it’s probably true that some psychiatrists did hold a purely biocentric view. And, alas, someundoubtedly used the expression “chemical imbalance” in their clinical practice, without putting itinto a broader context for their patients.It’s also true, as critics of the chemical imbalance hypothesis point out, that the term “imbalance” ismisleading. To validate an imbalance, we must first have a quantitative understanding of the optimalneurochemical balance in the brain—and, given the scores of neurotransmitters now identified, thisbalance has yet to be ascertained. That said, I am not aware of any concerted effort by academicpsychiatrists, psychiatric textbooks, or official psychiatric organizations to promote a simplisticchemical imbalance hypothesis of mental illness. That is what I meant when, in a 2011 PsychiatricTimes piece, I referred to the chemical imbalance hypothesis as an urban legend.4But still—shouldn’t psychiatrists in positions of influence have made greater efforts to knock downthe chemical imbalance hypothesis, and to present a more sophisticated understanding of mentalillness to the general public? Probably so. But there were sincere attempts to do just that, by anumber of prominent psychiatrists—beginning nearly 50 years ago, with the developers of thecatecholamine hypothesis. As psychiatrist Joseph Schildkraut and neuroscientist Seymour Kety wrotein 1967:Whereas specific genetic factors may be of importance in the etiology of some, and possiblyall, depressions, it is equally conceivable that early experiences of the infant or child may causeenduring biochemical changes, and that these may predispose some individuals to depressions inadulthood. It is not likely that changes in the metabolism of the biogenic amines alone will accountfor the complex phenomena of normal or pathological affect.5

Note the nuanced view of causality in this formulation—allowing for the possibility that chemicalchanges in the brain are effects of early experience, but also predisposing factors in somesubsequent depressive episodes. Note that Schildkraut and Kety did not argue that chemicalimbalances per se cause depression.Psychiatry’s critics also conveniently omit reference to what was arguably the most prevalentparadigm in academic psychiatry, during the 1980s and beyond—the biopsychosocial model of DrGeorge Engel.6 Now, the biopsychosocial model has been subjected to much criticism, and somewould argue that few psychiatrists nowadays employ the biopsychosocial model in a systematic,evidence-based manner.7,8 In 2001, Drs Glen O. Gabbard and Jerold Kay9 warned that“pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have becomefragmented from one another, creating an artificial separation of the psychosocial and biologicaldomains in psychiatry.”These are worrisome observations. But one thing is beyond dispute: the biopsychosocial model canhardly be reduced to a chemical imbalance theory of mental illness. As far back as 1991, in my bookon psychotherapy for the general public, I wrote: “In recent years, the ‘biopsychosocial’ model ofmental illness has gained prominence. This holds that mental problems have biological,psychological, and social roots. Therapy may therefore involve treatment in all three spheres.”10

I was far from the only psychiatrist to promote the biopsychosocial model—and none of my academiccolleagues, to my knowledge, publicly endorsed a simplistic chemical imbalance model as a blanketexplanation for all mental illness. Indeed, over 20 years ago, the late Dr Theodore Nadelson—one ofmy teachers and a highly respected psychiatrist—wrote in his foreword to my 1994 biopsychosocialtextbook on psychiatric diagnosis and treatment:Neuronal tissue grows in response to itsenvironment at least as much as it is obedient to any lockstep process choreographed immutablythe “gene machine.” We are creatures in nature, but we create our own nature. . . . If we are tounderstand patients and, as doctors, to help them, we require the broadest base. . . . [In addition tobiological research] we should also pursue greater understanding of the psychological and socialenvironment. That task is further informed by literature—poetry, philosophy, theater. That is our“biology” also.11

Ted Nadelson understood that the brain is the crucible in which all the elements of human lifeintermingle—including our genetic makeup; our brain chemistry; and the influences of parents,culture, ethnicity, and even diet. Derangements, deficiencies, or abnormalities in any of thesebiopsychosocial elements can lead to what we call, for lack of a better term, mental illness—whichoften represents the end result of innumerable interacting pathogens. Thus, in the introduction to

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Nuances, Narratives, and the “Chemical Imbalance” DebatePublished on Psychiatric Times(http://www.psychiatrictimes.com)

my 1994 textbook, I wrote that “the central assumption throughout the text is that the clinician mustbe able to integrate the complex biological, psychological and sociocultural data of the case athand.” Most well-trained psychiatrists, in my experience, have always understood this need anddone their best to fulfill it in practice.The Nobel Prize–winning psychiatrist and neuroscientist, Dr Eric Kandel, observed that “all mentalprocesses, even the most complex psychological processes, derive from operations of the brain . . .as a corollary, behavioral disorders that characterize psychiatric illness are disturbances of brainfunction, even in those cases where the causes of the disturbances are clearly environmental inorigin.”12(p39) But in practice, Kandel is no biological reductionist. He is certainly no fan of a chemicalimbalance hypothesis! Rather, Kandel paints a picture of the “new” psychiatry, in whichpsychoanalytic and biological constructs complement and reinforce one another. It is time forpsychiatry’s critics to drop the conspiratorial narrative of the chemical imbalance and acknowledgepsychiatry’s efforts at integrating biological and psychosocial insights.This article was originally posted online on 3/11/2014 and parts of it may have been updated. References: 1. Levine BE. Psychiatry now admits it's been wrong in big ways -- but can it change? Truthout.org.March 11, 2014. Accessed March 11, 2014.

2. What is Mental Illness? PDF. American Psychiatric Association's "Healthy Minds" website, 2005.Accessed March 11, 2014.

3. Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. JAMA. 2005; 294:2221-2224.

4. Pies R. Psychiatry’s new brain-mind and the legend of the “chemical imbalance. Psychiatric Times.July 11, 2011.

5. Schildkraut JJ, Kety SS. Biogenic amines and emotion. Science. 1967; 156:21-37.

6. Engel GL. The need for a new medical model: a challenge for biomedicine. Science.1977;196:129-136.

7. Kontos N. Perspective: biomedicine—menace or straw man? Reexamining the biopsychosocialargument. Acad Med. 2011;86:509-515.

8. Ghaemi SN. The rise and fall of the biopsychosocial model. Br J Psychiatry. 2009;195:3-4.

9. Gabbard GO, Kay J. The fate of integrated treatment: whatever happened to the biopsychosocialpsychiatrist? Am J Psychiatry. 2001;158:1956-1963.

10. Pies R. Psychotherapy Today: A Consumer’s Guide to Choosing the Right Therapist. Manning,Skidmore, Roth, 1991.

11. Nadelson T. In, Pies R: Clinical Manual of Psychiatric Diagnosis and Treatment: A BiopsychosocialApproach. Arlington, Va: American Psychiatric Press; 1994.

12. Kandel ER. Psychiatry, Psychoanalysis and the New Biology of Mind. American PsychiatricPublishing, Washington DC, 2005. Source URL: http://www.psychiatrictimes.com/blogs/couch-crisis/nuances-narratives-chemical-imbalance-debate

Links:[1] http://www.psychiatrictimes.com/blogs/couch-crisis[2] http://www.psychiatrictimes.com/cultural-psychiatry[3] http://www.psychiatrictimes.com/psychopharmacology[4] http://www.psychiatrictimes.com/authors/ronald-w-pies-md

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Nuances, Narratives, and the “Chemical Imbalance” DebatePublished on Psychiatric Times(http://www.psychiatrictimes.com)

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